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Feet of Clay

It has been tough in Portland this year. The Trailblazers, our NBA, and only professional team, started out on a tear, then went right down the toilet. It is painful to see such promise dribbled away. Sigh. Why is elation always followed by disappointment? Everyone and everything has feet of clay. Except Cassius Marcellus.

At the beginning of March the NEJM had a wonderful essay, What’s the Alternative? The Worldwide Web of Integrative Medicine by Ranjana Srivastava. The essay concerns a patient who is ‘diagnosed’ with cancer at an integrative medicine exhibition and the resultant diagnostic and therapeutic debacles that follow.

The quotes of note:

“At one time, the worst offense one encountered was someone prescribing a few herbs to a desperate patient who’d exhausted all other means of treatment. The usual thinking was, “At this stage, it can’t do any harm.” But insidiously and alarmingly, “alternative medicine” has crept from offering last-ditch treatments to making diagnoses. As the cancer armamentarium has expanded with targeted therapies, unscrupulous practitioners of alternative therapy have devised competing offers that sound at least as impressive to the average patient, who is often marginally health-literate and eager to embrace the promise of a cure without toxicity. But the radical, completely unregulated, and often dangerous options on offer can and do cause harm.

and

Alternative therapies need meet no burden of proof except a patient’s gullibility. One never hears of alternative therapies that failed: the patient merely waited too long to try them.

and

Physicians would be naive to ignore the elephant in the room. Integrative medicine comes in many forms — some useful, but many dangerous. It also comes at tremendous personal and societal cost. The initial expenditure may come from patients’ pockets, but often the health care system eventually inherits the problem. Although there’s probably no way of calculating the psychological cost, for many it is high and unending.

Well said. This editorial and patient story concerns cancer, not a relatively trivial problem, but the concepts are widely applicable to all manner of SCAMs. I am not a big fan of slippery slope arguments, but I am always concerned when useless or unproven therapies are recommended. I am also not a fan of ideological purity, a foolish consistency being the hobgoblin of little minds, adored by little statesmen and philosophers and science bloggers. The key word I suppose is foolish. There is nothing foolish about being serious in protecting your patients life, health, and, given the cost of care, wealth.

Fast forward a mere two weeks to Clinical Practice. Uncomplicated Urinary Tract Infection by Thomas M. Hooton. I suppose the editors of the NEJM were experiencing an F. Scott Fitzgerald moment  when first they published

The phenomenon of questionable health practices is not limited to the developing world; my patient’s encounter occurred in a medically sophisticated city. Patients can even be duped at home, from the safety of their Internet connection.

only to be followed 14 days later with a review of the treatment of UTI where the editors were evidently paying no attention to the prior content of the Journal. I saw no disclaimer that the views of the Ranjana Srivastava were not those of the NEJM, so I assume the editors agreed. I know. Naive.

For in the table on prevention for UTI we find the following recommendations:

Cranberry juice, capsules or tablets

Biologic plausibility is based on the inhibition of uropathogen adherence to uroepithelial cells; clinical data supporting a protective effect have been limited by design flaws; a recent randomized, placebo-controlled trial showed no benefit from cranberry juice.

Adhesion blockers (D-mannose, available in health-food stores and online, is occasionally used as preventive therapy)

UTIs caused by E. coli are initiated by adhesion of the bacteria to mannosylated receptors in the uroepithelium by means of FimH adhesin located on type 1 pili; theoretically, mannosides could block adhesion; however, D-mannose has not been evaluated in clinical trials.

and it is noted in the discussion (talking in part about mechanical solutions such as voiding after intercourse as well as Cranberry juice and D-mannose)

Although data supporting the effectiveness of these strategies are sparse or nonexistent, they carry a low risk of adverse effects and may be helpful.

and

…although data on the efficacy of these measures are mostly lacking, they pose little risk.

Why not suggest homeopathy, reiki, acupuncture, purging and bleeding? The same concepts apply. I know that there are ‘sarcasm marks’, but on occasion I need ‘voice dripping with contempt’ marks or ‘I am so disappointed I want to cry’ marks when I write.

The data is negative or does not exist. Yet the NEJM recommends it anyway.  It can’t hurt; what’s the harm? For those of you not in medicine, the word of the NEJM is close to that of god. In clinical medicine, there is the NEJM then everyone else.  The recommendations are in a table that will be cut and pasted into a thousand Powerpoint talks and disseminated far beyond the readership of the NEJM.

To paraphrase:

The phenomenon of questionable health practices is not limited to the developing world; my encounter occurred in a medically sophisticated Journal. Doctors can even be duped at home, from the safety of their Internet subscription.

Years ago the Annals of Internal Medicine published a hideous series on alternative medicine and I lost confidence in the Annals and they have slid into personal irrelevance. When referring to the journal to housestaff I often pronounce it as if it had one ’n’, such is my ongoing irrational, immature, contempt for the Annals. Perhaps it is confirmation bias on my part. I expect the Annals to publish third rate articles and that is what I see. The NEJM isn’t Annals level. Yet. But it lies at the heart of my ongoing problem with all media: if they get it wrong in an area in which I am knowledgeable (Infectious Diseases, SCAMs) how can I trust them in areas in which I need to defer to the expertise of others (just about everything else)?

Is it me, or does the clay now extend to midthigh for the NEJM? Is there anyone I can trust?

Posted in: Health Fraud, Medical Academia, Pharmaceuticals

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